Benzodiazepine withdrawal

Background

Clinical Features

  • Onset usually several days to 1 week
  • More likely in patients with high doses or prolonged use
  • Autonomic hyperactivity (e.g., diaphoresis, HR>100, hyperthermia)
  • Nausea/vomiting
  • Tremulousness, psychomotor agitation
  • Anxiety, insomnia, irritability agitation
  • Psychosis (more common than in ETOH withdrawal)
  • Seizure

Differential Diagnosis

Sedative/hypnotic withdrawal

Seizure

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma

Psychiatric

Evaluation

Management

  • Ensure patient and staff safety, airway protection if acutely agitated or seizing
  • Benzodiazepines
    • Withdrawal from high-potency benzodiazepines (e.g. alprazolam) may require higher doses of traditional benzos like diazepam to achieve clinical effect
    • Consider substituting shorter half-life drugs with equivalent dose of diazepam
    • Equivalent diazepam dose = triazolam dose x 20 = alprazolam dose x 10 = lorazepam dose x 5
  • After acute symptoms controlled, can prescribe gradual benzo taper
    • One taper strategy: decrease dose by 25% for first week, 25% second week, then by 12.5% for subsequent weeks[1]
  • Consider neurology consult if patient was using benzos for seizure control (may need further antiepileptic management)

Disposition

  • Admit if:
    • Multiple seizures
    • Uncontrolled autonomic hyperstimulation
    • Decreased level of consciousness

See Also

External Links

References

  1. Chang  F: Strategies for benzodiazepine withdrawal in seniors. CPJ 138: 38, 2005.

Authors:

Claire